Chapter 17 prep u

a kindergarten student is sent to the school nurse because they have been vigorously scratching their scalp for a few hours. what is the nurse's priority?

assess for possible pediculosis

Lack of keratin on the nails can cause ?

brittle fingernails

pediculosis (lice)

brown crawling insects over the scalp - bites cause itching

caries

cavities

A nurse is providing oral care to a client with dentures. What action would the nurse perform first?

don gloves

bathing benefits

eliminating body odor reducing potential risk of infection stimulating circulation provides a refreshed feeling improves self-image

A nurse is brushing the hair of a client admitted to the health care facility following a fracture in the hand. The nurse implements this action based on the understanding that brushing the hair:

facilitates oil distribution.

T/F Older, continent clients who are hospitalized should receive a full bed bath with soap and water every day

false

tinea capitis

fungal infection that appears as a ring or cluster - causes itching and becomes scaly

What cell in the mucous membranes secrete mucus?

goblet

When an adolescent client asks the nurse how to care for long hair, the nurse should instruct the client that:

hair should be washed as often as necessary.

An older adult client is reporting dry, itching skin. The nurse should assess:

how often the client is bathing.

scabies

infestation of an itch mite that burrows

A client is admitted to the health care facility with a diagnosis of pediculosis capitis. What would the nurse expect to find in the client?

inflamed bites along the hairline

acne

inflammation of sebaceous glands and hair follicles

The nurse is caring for a client who has had multiple dental caries. Which food will the nurse encourage the client to avoid that is on the dietary tray?

jelly to go on the toast

Which client would be at greatest risk for injury to the skin and mucous membranes?

man 77 years of age with diabetes

skin cancer

newly pigmented growth

psoriasis

noninfectious chronic skin disorder - elevated silvery scales

The nurse working at a long-term care facility supervises while the unlicensed assistive personnel (UAP) bathes an older adult client. The nurse determines the UAP requires intervention when the UAP:

places a large quantity of soap on the washcloth.

A client expresses concern regarding the use of a bag bath. Which statement(s) by the nurse is appropriate? Select all that apply.

"The bag bath decreases the risk of skin breakdown because the cleanser lubricates the skin." "The bag bath will reduce the spread of bacteria since we are able to use separate cloths." "Bag baths actually promote comfort because the moist cloths are used quickly and are warmed when applied."

The nurse observes slight bruising on the client's left thigh during a bed bath and palpates a lump on the anterior surface of the thigh. Which will the nurse document on the electronic health record (EHR)?

"During bed bath, slight bruising noted on left thigh. 5 cm hard lump palpated on anterior surface of the thigh."

The nurse is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which statement by a family member requires further nursing instruction?

"I should provide soap for daily bathing to remove debris and keep my loved one's skin moist."

The acute care nurse is talking with a client who just finished performing oral care. The client states, "I have some whitish-yellow patches on my tongue. Should I be concerned?" How should the nurse respond first?

"Let me assess the patches. They may indicate the development of a fungal infection."

A sitz bath would be most appropriate for which client?

33-year-old who is one day postpartum

Which client is most at risk for foot difficulties?

45-year-old woman with type 2 diabetes

The nurse is caring for four clients. For which client is a sitz bath most appropriate?

51-year old with hemorrhoids

An 80-year-old woman tells the nurse that she just itches all the time and her skin seems very dry. How do these symptoms relate to aging skin?

Activity of the glands in the skin lessens.

kindergarten student is sent to the school nurse because they have been vigorously scratching their scalp for a few hours. What is the nurse's priority action?

Assess for possible pediculosis.

The nurse's oral assessment reveals inflamed gums. What is the nurse's best initial action?

Assess the client's dental care routines

The nurse is caring for a client who suffered a head injury and is beginning to perform activities of daily living with some assistance. When preparing to assist the client to take a shower, which action will the nurse take first?

Assess the client's level of consciousness.

A nurse is caring for a client who cannot swallow or expectorate. What interventions to keep the mouth and throat free of accumulating secretions should the nurse perform when caring for this client? Select all that apply.

Assist the client to a lateral position. Arrange for suctioning to remove mucus. Provide frequent mouth care.

A nurse is teaching a family member how to bathe the female bedbound client. What information should the nurse tell the client about perineal care?

Clean, using a washcloth, from the pubic area toward the anal area.

An older adult client with Parkinson's disease is unable to take perform self-care activities. The client frequently soils the bed and is unable to clean himself independently. How should the nurse in this case ensure the client's perineal care?

Cleanse to remove secretions from less soiled to more soiled areas

sordes

Dried mucus or food caked on the lips and teeth

The student nurse is providing a bed bath to a client with limited mobility. Which action should the student perform during this task?

Fold the washcloth like a mitt on your hand so that there are no loose ends.

A nurse is examining an adult client with inflammation of the gums. The nurse observes bleeding gums. What additional information should the nurse acquire to help determine next steps?

How often the client brushes and flosses the teeth

A nurse is assisting a client with his bed bath. The client states, "I can do it myself." Which is the nurse's best response

I will set up your bath for you, use the call button to let me know if you need me. pg 368-370

Sitz bath

Immersion of the buttocks and perineum in a small basin of continuously circulating water, removes blood urine stool or serum

If client has pediculosis, what intervention will the nurse provide?

Launder gowns, linens, and towels separate from other clients' items

The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide?

Launder gowns, linens, and towels separate from other clients' items.

what does the nurse recognize as the MOST important of the oral care process

a thorough, mechanical cleaning

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which technique for cleaning the penis is correct?

Retract the foreskin while washing the penis, and then immediately pull the foreskin back into place.

contact dermatitis

allergic sensitivity - red skin rash and itching

A nurse is shaving the facial hair of a client confined to bed. What is a recommended guideline for this procedure?

Shave with the direction of hair growth in downward, short strokes.

A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline?

Store dentures in cold water when not in use.

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care?

The client should be placed in a side-lying position to prevent aspiration

The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide?

Use an electric razor for shaving purposes.

A nurse is educating an adolescent regarding care of acne that is present on the face and neck. What actions should the nurse educate the client about that will promote healing and prevent outbreaks?

Use oil-free, water-based moisturizers and makeup.

Opthamologist (MD)

a doctor who treats eyes and their diseases

How much shaving cream should you use on a client

a layer about 0.5 in thick

The nurse is providing oral care to a client who is unable to complete their own activities of daily living. While providing care, the nurse notices some bleeding. Following a full assessment and chart review, which potential cause(s) of oral bleeding will the nurse use to create a patient-centered plan of care? Select all that apply.

prescription for warfarin, diagnosis of peritonitis, current chemotherapy treatment, and low platelet count

a nurse is caring for a client who cannot swallow or expectorate. what interventions to keep the mouth and throat free of accumulating secretions should the nurse perform? Select all that apply.

provide frequent mouth care, arrange for suctioning to remove mucous, assist the client to a lateral position

furuncle (boil)

raised pustule - area that feels hard and painful

What is the right technique for cleaning the penis

retract foreskin while washing and then immediately pull foreskin back into place

What type of bath is preferred to decrease the inflammation after rectal surgery?

sitz bath

The nurse is caring for a client with tinea cruris. What assessment findings does the nurse anticipate finding?

sore, itchy cluster of scaly, cracked vesicles

opometrist

specialist for measuring vision

fungal nail infection

thick, yellowed rough appearing toe and fingernails

The nurse provides care for a female client having difficulty urinating after a vaginal hysterectomy. Which strategy(ies) does the nurse use to assist the client with urinary elimination? Select all that apply.

turn on water in the bathroom, pour warm water over the perineum, place client in sitting position, and provide a sitz bath

The nurse is preparing to provide oral care for a client who is alert but has bilateral weakness and requires assistance with all hygiene activities. When reviewing the medication administration record, the nurse notes the client has been prescribed low-dose acetylsalicylic acid. Based on this finding, which action will the nurse prioritize when providing assistance with hygiene?

use a soft-bristle toothbrush for mouth care

Nurse caring for a client who is on warfarin therapy will use what kind of razor

use an electric razor for shaving

A nursing student is caring for a client with dentures. Which action by the nursing student would require intervention by the nurse?

using ungloved hands to remove an unconscious client's dentures

candidiasis

yeast infection of the mouth or vagina